Center News Magazine: Surgery’s Vital Role in Treating Cancer

Peter Scardino, Chair of Memorial Sloan Kettering’s Department of Surgery, discusses the variety of treatment strategies offered by the prostate cancer team, from active surveillance to removal of the prostate gland – a procedure called radical prostatectomy.

In addition to his administrative responsibilities, Peter T. Scardino, Chair of the Department of Surgery, specializes in the surgical treatment of prostate cancer. In 1998, he was recruited by Memorial Sloan Kettering to head the program in urology and further develop the prostate cancer program. In 2006, Dr. Scardino was appointed to his present position. Here, he discusses the vital role surgery plays in current cancer treatment.

Can you talk in broad terms about the role of surgery in the treatment of cancer today?

Cancer care in the second decade of the 21st century is still largely about the surgical treatment of the disease. The vast majority of people with cancer have surgery as their main or only treatment. It remains the most effective treatment, it is growing in its applications, and it’s getting better all the time.

How many operations does Memorial Sloan Kettering perform annually?

We do more than 20,000 every year. Each of our surgeons specializes in a particular type of cancer, and they are as experienced as anyone in the world at the types of procedures they do.

How many Memorial Sloan Kettering patients have surgery as part of their treatment?

We did a study several years ago in which we looked at more than 20,000 Memorial Sloan Kettering patients who came for treatment here and were followed for seven years. Nearly 50 percent of them had surgery as their only treatment and more than 70 percent had surgery as part of their treatment, along with chemotherapy, radiationtherapy, or both.

“What you get at Memorial Sloan Kettering is not only a great surgeon and a great operation, but a surgeon who understands when and how to incorporate surgery into the total treatment plan of each patient.”

—Peter Scardino, Chair, Department of Surgery

Where is the surgical treatment of cancer headed?

The role of surgery is changing and expanding. We are making real progress in understanding cancer genetically and developing remarkable new targeted drugs that are highly effective against cancer — initially. But almost all solid tumors — lung, breast, colon — come back. So these drugs by themselves are not leading to permanent cures. As the multidisciplinary treatment of cancer grows more complex, surgery is also getting more challenging. Cancer surgeons are doing increasingly complicated and difficult operations, because we know that in many cancers the right combination of drug treatment and surgery gives much better results than either alone.

So this is where the role of a place like Memorial Sloan Kettering becomes so important.

Exactly. A surgeon from another institution said to me, “Memorial is the hospital where we send patients when we feel the operation can’t be done anywhere else.” We have nearly 100 highly experienced, very sophisticated surgeons, all of them leaders in their fields, who are constantly exploring how to make surgery safer and more effective, how to do operations for patients with advanced cancers — in other words, cancers that have spread — and when to use surgery in combination with the appropriate drugs or other therapies.

So an exclusive focus on cancer is extremely important when you talk about surgery.

Yes. Because our surgeons deal only with cancer and are specially trained in oncology — not just in their surgical specialty — they have a deep knowledge of the disease. They understand the natural history of cancer, the different ways it manifests itself, and how to care for patients in a multidisciplinary setting. What you get at Memorial Sloan Kettering is not only a great surgeon and a great operation, but a surgeon who understands when and how to incorporate surgery into the total treatment plan of each patient.

Which brings us to the collaborative approach to care.

At Memorial, when you meet with a surgeon you’re meeting with a team. The team includes world-class pathologists, radiologists, medical oncologists, and radiation oncologists, all of whom collaborate to develop a treatment approach that will be most effective for each patient. Let me put it another way: Just because I’m a surgeon doesn’t mean I’m automatically going to say, “You need surgery.” There’s that old expression, “If all you have is a hammer, everything looks like a nail.” At Memorial Sloan Kettering, surgeons have a lot more than a hammer. They have the full repertoire of cancer experts, all of whom are leaders in their fields. It doesn’t matter whether you treat the patient or I do — we work together and use whatever therapies are necessary to achieve optimal outcomes for our patients.

Let’s talk now about surgery in several specific cancers and start with your specialty, prostate cancer.

Again, we’re talking about a team that’s much broader than surgery. We partner with our colleagues in medical oncology, radiation oncology, pathology, and radiology — all of whom have a singular focus on prostate cancer — to arrive at a complete picture of each individual’s disease and decide how best to treat it.

Why should a patient come to a member of your prostate cancer surgical team?

Each of us is expert in the type of surgery we do, whether open, laparoscopic, or robotic radical prostatectomy. We perform 800 to 900 prostate surgical procedures a year. Roughly half are open and half are robotic. But the skill and experience of the surgeon makes the difference, not what tools are used — not only in the chances for a cure, but whether a man will suffer the side effects of surgery, which can include urinaryincontinence and sexual dysfunction. I should also note that not every man will require treatment, and we are skilled in evaluating each prostate cancer to determine which treatment, if any, a patient needs. Certain men do well with “active surveillance,” in which treatment is deferred because their cancer is unlikely to progress or become life threatening. Of course, we monitor these men carefully for any changes in the tumor’s characteristics that would make it wise to intervene with surgery or radiation.

Can you talk about Memorial Sloan Kettering’s surgical breast service?

Once again, the approach is collaborative. When you see a breast surgeon here, you’re not just seeing a surgeon expert at removing a lump, or even removing a breast if that proves necessary. You gain access to a highly sophisticated team — including breast cancer pathologists, radiologists, medical oncologists, and radiation oncologists — who apply the most-modern diagnostic tools to understanding your cancer and developing the most effective treatment plan possible. Our surgeons have the world’s largest experience in axillarylymph node dissection. And we have a group of gifted plastic and reconstructive surgeons able to perform extremely complex breast reconstructions, if these are required.

And what can you say about Memorial Sloan Kettering’s program in thoracic surgery?

Our thoracic surgeons deal exclusively with cancer, whether primary lung cancer, esophageal cancer, mesothelioma, or cancers that have metastasized to the lung. They’re pioneers in treating these complicated diseases, which often entail high-risk operations. They work with our medical oncologists and radiation oncologists to develop chemo-radiation treatments that can shrink tumors to make surgery possible and, sometimes, to allow a patient to avoid surgery altogether. They’ve pioneered ways of reconstructing the esophagus when it has to be removed, and we’re a leading center in the use of laparoscopic and robotic surgery in lung cancer as well as pioneers in robotic surgery for esophageal cancer. These surgeons are actively developing new devices to make operations safer and more effective. And they’re involved in developing the world’s first immunotherapy program for mesothelioma and adenocarcinoma of the lung, in collaboration with scientists in our Center for Cell Engineering.

Finally, what drew you to Memorial Sloan Kettering?

I came here 14 years ago because I wanted to work with the finest cancer experts in the world. I’m a surgeon. I can only do so much by myself. At Memorial Sloan Kettering I have extraordinary colleagues completely committed to understanding and eventually curing cancer. This is the place to be if you want to be among the very best.

adenocarcinoma (A-deh-noh-KAR-sih-NOH-muh)

Cancer that begins in cells that line certain internal organs and that have gland-like (secretory) properties.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

axillary (AK-sih-LAYR-ee)

Pertaining to the armpit area, including the lymph nodes that are located there.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

breast (brest)

Glandular organ located on the chest. The breast is made up of connective tissue, fat, and breast tissue that contains the glands that can make milk. Also called mammary gland.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

cancer (KAN-ser)

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is a cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord. Also called malignancy.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

chemotherapy (KEE-moh-THAYR-uh-pee)

Treatment with drugs that kill cancer cells.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

cure (kyoor)

To heal or restore health; a treatment to restore health.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

drug (drug)

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

dysfunction (dis-FUNK-shun)

A state of not functioning normally.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

esophageal (ee-SAH-fuh-JEE-ul)

Having to do with the esophagus, the muscular tube through which food passes from the throat to the stomach.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

esophagus (ee-SAH-fuh-gus)

The muscular tube through which food passes from the throat to the stomach.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

immunotherapy (IH-myoo-noh-THAYR-uh-pee)

Treatment to boost or restore the ability of the immune system to fight cancer, infections, and other diseases. Also used to lessen certain side effects that may be caused by some cancer treatments. Agents used in immunotherapy include monoclonal antibodies, growth factors, and vaccines. These agents may also have a direct antitumor effect. Also called biological response modifier therapy, biological therapy, biotherapy, and BRM therapy.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

incontinence (in-KON-tih-nents)

Inability to control the flow of urine from the bladder (urinary incontinence) or the escape of stool from the rectum (fecal incontinence).

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

lung (lung)

One of a pair of organs in the chest that supplies the body with oxygen, and removes carbon dioxide from the body.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

lymph (limf)

The clear fluid that travels through the lymphatic system and carries cells that help fight infections and other diseases. Also called lymphatic fluid.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

mean (meen)

A statistics term. The average value in a set of measurements. The mean is the sum of a set of numbers divided by how many numbers are in the set.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

mesothelioma (MEH-zoh-THEE-lee-OH-muh)

A benign (not cancer) or malignant (cancer) tumor affecting the lining of the chest or abdomen. Exposure to asbestos particles in the air increases the risk of developing malignant mesothelioma.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

monitor (MAH-nih-ter)

In medicine, to regularly watch and check a person or condition to see if there is any change. Also refers to a device that records and/or displays patient data, such as for an electrocardiogram (EKG).

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

multidisciplinary (MUL-tee-DIH-sih-plih-NAYR-ee)

In medicine, a term used to describe a treatment planning approach or team that includes a number of doctors and other health care professionals who are experts in different specialties (disciplines). In cancer treatment, the primary disciplines are medical oncology (treatment with drugs), surgical oncology (treatment with surgery), and radiation oncology (treatment with radiation).

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

oncology (on-KAH-loh-jee)

The study of cancer.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

prostate (PROS-tayt)

A gland in the male reproductive system. The prostate surrounds the part of the urethra (the tube that empties the bladder) just below the bladder, and produces a fluid that forms part of the semen.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

prostate cancer (PROS-tayt KAN-ser)

Cancer that forms in tissues of the prostate (a gland in the male reproductive system found below the bladder and in front of the rectum). Prostate cancer usually occurs in older men.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

prostatectomy (PROS-tuh-TEK-toh-mee)

An operation to remove part or all of the prostate. Radical (or total) prostatectomy is the removal of the entire prostate and some of the tissue around it.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

radiation (RAY-dee-AY-shun)

Energy released in the form of particle or electromagnetic waves. Common sources of radiation include radon gas, cosmic rays from outer space, medical x-rays, and energy given off by a radioisotope (unstable form of a chemical element that releases radiation as it breaks down and becomes more stable).

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

radiology (RAY-dee-AH-loh-jee)

The use of radiation (such as x-rays) or other imaging technologies (such as ultrasound and magnetic resonance imaging) to diagnose or treat disease.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

surgeon (SER-jun)

A doctor who removes or repairs a part of the body by operating on the patient.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

surgery (SER-juh-ree)

A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

surveillance (ser-VAY-lents)

In medicine, the ongoing collection of information about a disease, such as cancer, in a certain group of people. The information collected may include where the disease occurs in a population and whether it affects people of a certain gender, age, or ethnic group.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

therapy (THAYR-uh-pee)

Treatment.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

thoracic (thor-A-sik)

Having to do with the chest.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

urinary (YOOR-ih-NAYR-ee)

Having to do with urine or the organs of the body that produce and get rid of urine.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

vital (VY-tul)

Necessary to maintain life. Breathing is a vital function.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)

will (wil)

A legal document in which a person states what is to be done with his or her property after death, who is to carry out the terms of the will, and who is to care for any minor children.

Source: The National Cancer Institute's Dictionary of Cancer Terms(http://www.cancer.gov/dictionary)